Provider Demographics
NPI:1033870654
Name:BURNS, SCOTT (PA)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:
Last Name:BURNS
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:SCOTT
Other - Middle Name:A
Other - Last Name:BURNS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2790 GODWIN BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23434-8151
Mailing Address - Country:US
Mailing Address - Phone:757-983-8750
Mailing Address - Fax:
Practice Address - Street 1:2790 GODWIN BLVD STE 100
Practice Address - Street 2:
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23434-8151
Practice Address - Country:US
Practice Address - Phone:757-983-8750
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-05
Last Update Date:2023-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
VA0110008726363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program